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....aC�► Uniform to and Used 'Fire iVlanif California Integrated Waste Management Board <br /> PO Box 1259, Sacramento,CA 95612-1259 <br /> EXAMPLE 2 3 Manifest Number <br /> IIII7 <br /> State Of California INSTRUCTIONS ON BACK M l " 1 1 5 0 6 3 4 <br /> CIWM&647(03/03) <br /> PART I: TO BE COMPLETED BY TIRE HAULER (please print) <br /> ❑ Pick Up �� <br /> El Import from _ ) <br /> (If outside California State/Country) j-7 <br /> ❑Delivery cjq C� - <br /> ❑ Export to <br /> (If outside Califomia State/Country) Ha(l s BusinessPhone <br /> (include area codedeUX <br /> L J _ 1 ! / Hauler Exemption (if applicable) <br /> El Government ❑LEA Exempt <br /> Load Date (MM/DD/YY) Log Number ❑Agriculture ❑ Common Carrier/ <br /> Back Haul <br /> CD 3 0 `7Cj Indicate(if applicable)E] In Transit <br /> License Plate qunri State Decal Number 6 <br /> ❑Confidentiality Claim: The information provided in Part I and Part II of this form should be considered confidential,proprietary,and/or trade secret.In <br /> accordance with Title 14,CCR,Section 17041 et.seq,should any member of the public request disclosure of this information, I request that CIWMB contact <br /> me at the address and telephone number above. <br /> I certify that under penalty of porjury under the laws of the State of Califomia that the information provided above is true and correct. In addition,I am aware that falsification of this <br /> information may result In suspension,revocation,or denial of renewal of the Waste Tire Hauler Registratio ursuant to Public Resources Code section 42960 and may result in civil <br /> penalties to$25,000 qdper violation or administrative penalties up to$5,000 per violation per d as described in Pubf Resources Code section 42962. <br /> Drive 's Name(print) Drive Signature Date <br /> PART II: TO BE COMPLETED BY REPRESENTATIVE OF TIRE DEALER OR WASTE TIRE GENERATOR OR END-USE <br /> FACILITY (please print)- USE ACTUAL LOCATION WHERE THE TIRES ARE PICKED-UP OR DROPPED OFF. <br /> Opw Aya 1h. IA,&Je- <br /> Business Name Facility's Business Phone (include area code) <br /> Number&Street Address <br /> f ^ , , l ❑Address Same As Hauler <br /> d ❑Change Of Address <br /> City Stat�weVVV Zip Code <br /> Tire Types and Amounts Intended Use <br /> ❑Passenger ❑Oversize >0 Retread/Reuso <br /> Tire Program ID Site Suffix ❑ Recycle <br /> co <br /> Load Type(check only one) if1 Truck ❑Other ❑ Fuel <br /> ❑Whole Tire Count ❑Weight In Pounds c <br /> ❑Volume Cubic Yards ❑Weight in Tons �7 <br /> �, ❑ Disposal/Landfill <br /> CIL <br /> Load Amount O Comment Area <br /> ow <br /> ❑Confidentiality Claim: The information provided in Part I and Part II of this form should be considered confidential,proprietary, and/or trade secret. <br /> In accordance with Title 14,CCR,Section 17041 et.seq, should any member of the public request disclosure of this information, I request that CIWMB <br /> contact me at the address and telephone number above. <br /> I camiy that under penally of perjury under the laws of the State of California that the ormation provided above is true and correct.In addition,I am aware that falsification of this <br /> information may result in civil penalties up to$25,000 per day,per violas on or adm rative nalti up to$5,000 per violation per day as described in Publi Resources Cade <br /> section 42962. <br /> ")I'- �N Z"o <br /> Repres ntative Name(print) esentative's Signature a 32876 <br /> ® Toll Free 1-866-8e6-f0(600 / www.Ciwmb.ca.gov/Tires/ O ■ <br /> White:CIWMB Copy PinKI lire Dealer/Generator/End-Use"Facility Copy Yellow:Hauler Copy <br />